The black hole known as the emergency room

Spend enough time in healthcare circles and you will find that folks talk a lot about the “ER”. Yes, the emergency room, one of the most costly places to receive healthcare services in the entire US healthcare system. From the NYT:

“Emergency room bills are notoriously high and perplexing; patients often are left feeling like captives who have few alternatives. It is impossible to know how much the services will cost when you walk in the door. The hospital bill, which arrives weeks later, may include seemingly inflated charges for things like Tylenol or an M.R.I. Doctors who treated you may send their own separate bills, further complicating the payment process.”

If one looks at the Agency for Healthcare Research and Quality (AHRQ) Medical Expenditure Panel Survey (MEPS) data, the average expenses for folks who had one or more visits to the ER were $1318 in 2009. Median cost was $615, and for people 45 – 64, the cost was significantly higher than the average ($1696). The uninusered were by far the costliest in the ER (on average $1397; 37% paid out of pocket for these visits compared to Medicare patients who pay 4% to 6% out of pocket). Kids under age 18 were in the $465 to $469 range. These data can be seen here on the MEPS site. While these numbers may seem small in comparison to the trillions spent on healthcare, they definitely add up (how many million are uninsured??).

So let’s take a step back and look at the emergency room itself, and why services in this setting are so important. From Wikipedia:

“An emergency department (ED), also known as accident & emergency (A&E), emergency room (ER), emergency ward (EW), or casualty department is a medical treatment facility specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance. The emergency department is usually found in a hospital or other primary care center. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care.”

It likely goes without saying that there are various times in our lives when we need emergency healthcare services. And make no mistake, many times access to these services saves lives – this is why we have a portion of our system that can take care of emergencies. However, “it’s quite typical for a patient to enter the ER with symptoms indicating a serious medical condition but leave with a diagnosis that sounds anything but urgent. Imagine, for example, the common scenario of a 50-year old man with a heart condition who comes to the ER complaining of crushing chest pain but, after a medical work up, is found to be suffering from indigestion.”

And this is the heart of the problem with emergency room services – because of their nature to assess, treat (if appropriate) and be readily available, they become one arm of the system that has the potential to be misused or overused. ER services do not require planning, in fact, this is counter to their function. ER services are for health emergencies; those unpredictable events that you cannot anticipate happening.

If I have no health insurance, I am likely to not see my primary care physician for prevention, chronic disease management and health behavior change. If I have no health insurance, I am likely to let some of my health problems “go” as I don’t have the resources to pay for an office visit (nor am I likely to ask how much the services I receive in an office visit will cost). To this end, the ER becomes my safety net; a place where I can always turn if it gets bad enough for me to really worry. As the classic RAND health insurance experiment showed, “patients use more healthcare (even if it doesn’t make them healthier) when they don’t bear much of the cost directly. In the E.R., a single $100 co-pay may feel like a relative bargain compared with the alternative: fees for multiple trips to the doctor and testing centers, hours on the phone arranging the whole process, and days of missed work.”

And this is what is happening throughout the country. Or is it? No doubt, the ER has become an over-utilized service that remains a high driver of healthcare cost, but when happens when we break down the data and look at who is actually using the ER services? What do we find?

Well, surprisingly many of the folks showing up in the ER have insurance. From Slate: “In fact, the uninsured don’t even use the E.R. any more often than those with insurance do.” The authors point out that one study showed that the “increased use of the ER over the past decade (119 million U.S. visits in 2006, to be precise, compared with 67 million in 1996) is actually driven by more visits from insured, middle-class patients who usually get their care from a doctor’s office” than from the uninsured.

So what is about us that even when we have access to traditional healthcare services, we still look to the ER for the answer?

I think the answer is twofold.

First, there is an information issue. Many times the information written about me stored on an electronic medical record may not be accessible to the person it matters the most to (me). I may only know what I remember from my office visit, and in the face of a health emergency, may forget all this anyway. While it remains to be seen how much personal health records and access to our health data will help decrease ER misuse, there is something there worthy of examining. We must have better access to our own health information.

Second, we must work on changing our attitudes on healthcare from “instant gratification” and “reactive” to a more “planned and informed” or “proactive” approach. The easiest example of this is that oftentimes it is easier to take a pill than do a more complicated routine of multiple health behaviors. The pill “gets it done” fast with little or no effort on my part. The same can be said for the ER. The ER is there, easy for me to access, and therefore why worry about that nagging pain in my chest? If it gets any worse, I can always go to the ER (please note, these are just examples and I do realize that nothing is as simple as I am making it). There is an underlying attitudinal change that must occur in healthcare prior to us seeing behavior changes in the healthcare system.

As more innovative healthcare programs emerge, many of them are choosing to focus on decreasing ER utilization as one way to drive down overall healthcare costs. These programs should be encouraged and will likely yield many positive results; however, we must start to look at some of the underlying issues at play here and consider the “why” questions. Why are patients using the ER in the first place? Why do we keep so much of the information about the patient in a place the patient cannot use it? And the list goes on and on.

The black hole known as the ER will eventually become anything but a black hole. Trends in healthcare spending simply will not allow for patients to continued to be “sucked in” to this setting at the level they are now. This will change, and it is time for us to consider how to change it.

What has your experience been with the ER? Why do you believe these services are so often over used?

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

Ben, thank you for the detailed, thought provoking post. The depth of the data you site is extremely valuable in identifying and understanding the challenges associated with the high cost of emergency care.

I’m often reminded of Hanlon’s Razor: “never attribute to malice what can be adequately explained by [ignorance].” In this case, I don’t think anyone set out to design an ER as the costly bastion of controversy it is today. The ignorance in this case – truly not a knock – was how the payment structures would influence the design. 25 years ago, those with employer provided insurance didn’t have big co-pays or deductibles. Like you suggest, at worst, an ER visit resulted in a $50-%100 bill (still the case for many common commercial plans). On the other side, providers saw payors willing to shell out big bucks for emergency services. So it was easy to financially rationalize high charges since they weren’t going to trickle down to most people anyway.

For the average patient, the relatively small financial consequence was (and may still be) justifiable when you need care quickly and on your schedule. Pain is pain, and if you are doubled over a broken arm, $100 is probably worth it for someone with commercial insurance. And…if you can justify that for a broken arm, why not a sinus infection or stomach bug? After all, it beats calling a physician’s office and being told there is a 3 day wait for an appointment which will surely run late anyway.

Fast forward to today and we have high deductibles, larger co-pays and other financial disincentives to use the ER. Payors – driven by pressure from employers – have started to make it less attractive to use the ER as primary care.

BUT, the high charge profit center remains. Hospitals have built an ecosystem around those high charges because the margins are generally quite good (and it’s important to recognize they may be offsetting losing areas elsewhere in the hospital, it’s not all profit).

So what we have is a fundamental design flaw attributed to unforeseen effects of the payment structure.

That design flaw manifests itself most voraciously to the un-and-underinsured. It is also starting to creep towards those with high deductibles and co-pays. We conditioned ourselves to think of the ER as “on demand care” (a point you speak to quite well).

For me, that all points to the next design challenge: bridging the gap between primary care and emergency care. We’re seeing that in the form of urgent care centers, a practical hybrid approach for those less acute, but nonetheless time sensitive needs. The beauty of urgent care, besides being available at the patient’s time of need, is that those centers do not see thing more complicated than E&M Level 2 or 3 and so don’t need a full cath lab, MRI, and helipad. Their costs are lower as a result.

Another solution, slightly counter to the idea of reconditioning patient/community thinking about emergency care, is to rethink the primary care access model. Many are using the ER for low acuity visits because of perceived barriers accessing primary care – long waits, delayed appointments, “sick” rooms, and general inconvenience. If we re-thought ways to provide easy, consumer driven access to lower cost care settings, we might also see a shift away from the high cost ER environment: online booking, walkin appointments, early and extended hours, eVisits … they’re all starting to emerge.

Now, none of that helps those who cannot overcome the most primary but also impassable barrier – insurance… Although, wouldn’t providers rather write off a lost cost office or urgent care visit than a high cost ER visit?

http://flavors.me/collaborativecare Ben Miller

Nick, you are an all star who will change the game in healthcare. Thank you for your thoughtful reply to this post. I wholeheartedly agree with you that this is a design issue. There are connections issues, as you point out, but there are also value issues (primary care/ specialty care). The system will self-correct some of this imbalance, it has to, but for now we are stuck identifying the problems and being as innovative as possible to create the solutions. Thank you!

http://www.planetree.org/ JoelHigh

I agree with both of you fine gents. Patient centered care needs to extend to the ED as well as the rest of healthcare. We have some bright spots such as the recent renonvation and process redesign at Northern Westchester Hospital in New York and well as the Lean redesigned ED at Sharp Memorial in San Diego. Patient centered care approaches and practices may be as important in emergency medicine as anywhere especially because many folks are even more frightened and anxious in the ED then they are any where else. Perhaps when the dollars don’t exist for process and facility redesign a bit of compassion and kindness can make the difference in experience.

http://www.nickdawson.net Nick Dawson

Joel, as always you are succinct and eloquent! Your last sentence goes a long way towards addressing the core issues facing healthcare. Turns out, when you focus on kindness, it always feels better for the practitioners and staff.

Outreach and education in healthcare is becoming more and more difficult to find as managed care decreases the amount of time that both a nurse or physician can spend with their patients. Healthcare is difficult to navigate for the those with higher education, it can be down right daunting. Explaining the tier of healthcare coverage and their purpose is something that takes repeated explanation in my practice. In the inner city population I care for – I have used a 6th grade simple decision tree on chosing the care option… this has helped…